Provider Demographics
NPI:1861729675
Name:VACHON, GARY ALAN (RPH, MM)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:ALAN
Last Name:VACHON
Suffix:
Gender:M
Credentials:RPH, MM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 ALGER ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3806
Mailing Address - Country:US
Mailing Address - Phone:616-490-0111
Mailing Address - Fax:
Practice Address - Street 1:3876 E PARIS AVE SE
Practice Address - Street 2:SUITE 13
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-3974
Practice Address - Country:US
Practice Address - Phone:616-777-0340
Practice Address - Fax:616-855-0937
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020254731835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy